spotlight on promising practices: affecting change in … 1... · note: that personal health...
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SPOTLIGHT ON PROMISING PRACTICES:
AFFECTING CHANGE IN THE SOCIAL
DETERMINANTS OF HEALTH TO DRIVE
IMPROVEMENTS IN BIRTH OUTCOMES
Monday, May 21
1:30 PM - 3:00 PM
#prematuritycollab
F LE D A M A S K J A C K S O N
M A J A IC A , LLC
S A V E 1 0 0 B A B IE S
Intersectionality, Contextualized Stress and Birth Equity
Racism Matters
Mortality among infants of black as compared with white college-educated parents. Schoendorf KC, Hogue CJ, Kleinman JC, Rowley D. N Engl J Med. 1992 Jun 4;326(23):1522-6.
Preterm delivery and low birth weight among first-born Infants of black and white college graduates. McGrady GA, Sung JFC, Rowley DL,
Hogue CJR Am J. Epidemiol (1992) 136(3),266-267.
Race and Gender Matter: From the Margins to the Center
Intersectionality (Race, gender, and class); Kimberely Crenshaw: Critical Race Theory
Interlocking systems of oppression; Patricia Hill Collins
Gendered Racism; Philomina Essed
Moving theory into measurement: Listening to the voices of
the women
Mixed methods: Robust procedure
Grounded theory: From the margins to center
Jackson, Hogue, Phillips Contextualized Stress Measure: validated and reliable measure;
Cronbach’s Alpha 0.84- 0.88
From the voices of the women
Jackson, Hogue, Phillips Contextualized Stress Measure
Chronic stressors from the intersection of identities; determinant and personally mediated experiences of oppression (racism, sexism, economic inequity)
Composite of chronic racial and gendered stressors, stress mediators, and affective responses; indications of high, moderate, and low exposure (tertiles)
Shielding black children from racism and violence, racial and gender discrimination in the workplace, community-level inequities, financial strain, physical, emotional and sexual abuse, gendered role and responsibility overload
Stress mediators: social support (friendship, family and father support); history and culture; religion and spirituality
Affective stress responses: anger, isolation, overwhelmed, lack of control)
Contextualized Stress and Birth Inequity
Stress, including stress from discrimination as as a significant risk for disproportionately adverse birth outcomes (physiological and emotional and mental health responses)
Significant association and regression for contextualized stress and antenatal depression for AA women across SES categories
Research findings on racial and gendered stress and antenatal depressive symptoms
Jackson, FM, Rowley, DL, Owens TC (2012).Contextualized Stress, Global Stress, and Depression in Well-Educated Pregnant African American
Women. Women’s Health Issues, 22-3, e329-336
Jackson FM, James S, Owens TC, Bryan AF. (2017). Anticipated Negative Police-Youth Encounters and Depressive Symptoms among Pregnant
African American Women: A Brief Report. Journal of Urban Health, Volume 94, Issue 2, pp 259–265.
Contextualized Stress, Global Stress, and Depression in Well-Educated Pregnant African American Women
101 majority (62%) college-educated African American women; 89% married or partnered; 41% HH income above 51K
Administered JHP, PSS (perceived stress scale); Beck Depression Inventory (BDI)
Proportion of women with depression increased with every increase in JHP tertile scores
JHP significant predictor of antenatal depression (B=503;p<.001)
Anticipated Negative Police-Youth Encounters and Depressive Symptoms among Pregnant African American Women: A Brief Report
Preliminary results from larger study (JHP and Edinburgh Postnatal Depression
Larger study results (N=300); majority <high school; single 62%; 19,000 or less HH income 65%
35% depressive symptoms
JHP significant predictor of antenatal depressive symptoms (p<.01)
Anticipated Negative Police-Youth Encounters and Depressive Symptoms among Pregnant African American Women: A Brief Report
JHP items: African American youth are more likely to have negative encounters with law enforcement (41%); We are losing our African American boys and men (71%)
Logistic regression results: significant association for anticipated negative police encounters and depressive symptoms; only presence of
male child (children were less than) remained in the model
Recommendations
Screening for psychosocial pregnancy and maternal risks should include stress screening that is intersectional, contextualized
Interventions for antenatal and postpartum depression should include assessments of contextualized stress.
Underscore the mandate for determinant approached for preventing poor birth to ensure birth equity
We can interrupt the crisis of black infant mortality through:
Healthy Families
Enduring Faith
Positive Social Support
Safe Housing
Healthy Nutrition
Quality Education
Fair Employment
Accessible Transportation
Quality Health Care
Save 100 Babies© [email protected]
Infant Mortality in Communities Across Texas
Prematurity Prevention Summit: Building a Birth Equity MovementMay 21, 2018
David Lakey, M.D.
Chief Medical Officer
Vice Chancellor for Population Health
The University of Texas System
@DavidLakey_MD
www.utsystempophealth.org/
15
Infant Mortality Interactive Map and Reporthttp://www.utsystempophealth.org/imr-texas/
Infant Mortality Rate in Infants of White Mothers– Longview, Texas2011-2014
Infant Mortality Rate in Infants of Hispanic Mothers–San Antonio, Texas2011-2014
Infant Mortality Rate in Infants of Black Mothers–Houston, Texas2011-2014
Birth Outcomes: Temporal inconsistencies in the community
• Low year-to-year correlation at the zip code level in preterm birth rates
• High year to year correlation for maternal risk factors
• Further analysis needed
Smoking During Pregnancyin Infants of White Mothers –Dallas/Fort Worth, Texas2015
Healthy Families Project
Purpose:Improving pregnancy-related outcomes through evidence-based interventions
Objective of the project: Identify and design services that will enhance early entry and engagement into prenatal care in two selected counties
Target population: Low income African American (Smith county) and Hispanic (Hidalgo county) women
Funding:Texas Health and Human Services Commission – Women’s Health Program
Project OverviewImproving pregnancy related outcomes through evidence-based interventions
Stakeholder Feedback
Thank You!UT System Population Health Team
• Nagla Elerian, MS
• Jon Gibson, MS CS
• Mary Isichei, DNP, MSN, MPH
• Em Karimifar
• Sheila Kuschke
• Dorothy Mandell, PhD
• Zabin Marediya, MS
• Lark Needham
• Eileen Nehme, PhD
• Dan Oppenheimer, MFA
• Divya Patel, PhD
• Melissa Valerio, PhD, MPH
Funding Agencies
• University of Texas System
• Texas Department of State Health Services
• Texas Health and Human Services Commission
• Texas Department of Family Protective Services
Prematurity Prevention Summit: Building a Health Equity
Movement
Historical Redlining, SDOH & Infant Mortality
Arthur R. James, MD, FACOG
May 21, 2018
RWJF County Health Rankings, 2014* Added by art james
Factors affecting lifetime health outcomes: - 20% due to clinical experiences- 30% personal choice- Remainder due to factors largely or whollyOutside one’s control – these are the SDoH
Note: that personal health choices are also limited or shaped by external factors:- Tobacco & alcohol use as responses tochronic stress- Healthy diet limited by access to affordable healthy food- Exercise limited by access to safe placesto play, recreate
*Structural Determinants
(Causes)
*Social Determinants(Conditions)
(*Consequences)
“Opportunity Rich” “Opportunity Poor”
• High-quality education• Stable housing• Sustainable employment• Healthy and safe environment• Access to healthy food• Positive social networks• Political empowerment
Good health extends beyond the individual choices we make
Typical Indicators in Kirwan’s Opportunity Index*ALL Reflect Social Determinants of Health
*Child Opportunity Index: http://www.diversitydatakids.org
Kirwan’s Opportunity Index*Positive and Negative Neighborhood Influences on Well-Being
*Child Opportunity Index developed for DiversityDataKids.org*Child Opportunity Index: http://www.diversitydatakids.org
Infant Mortality and Opportunity (Social Determinants)
Life Expectancy: The Other End of the Life Course
White
Asian Hispanic
Black
Who lives in High and LowOpportunity
Areas:
• Patient choices are constrained by their community’s resources
• Particularly true of patients in poorly resourced communities
• Rx: Connect patients to the resources they need
• “Connection” should go beyond referral, to facilitating access
• Transportation
• Child care
• Home visits
• Lower opportunity communities should receive community development assistance
Why Is the Geography of Social Determinants Relevant?
Why Is the Geography of Social Determinants Relevant?
Our Zip Code influences Our health more than our
Genetic Code:
Historically Redlined Neighborhoods
Indian Reservations
Historical Policies That ShapedOur Neighborhoods
A Brief History of
Systemic Racism in
Housing Policy and
Practice
Racial Segregation
& Opportunity
Isolation
Zoning & Land Use Practices
Redlining & Investment
Practices
Urban Renewal, Public Housing & Federal Highway
Policies
Explicit Racial Discrimination &
Intimidation Practices
Historical Drivers of Racial Segregation and Isolation of Communities of Color
• Home Owner’s Loan Corporation (HOLC) created to Insure Home Mortgage Loans
• Risk maps in 239 cities to guide mortgage lending
Redlining: A Highly Racialized Practice
Redlining: A Highly Racialized Practice• Local real estate professionals, bankers and others assessed a city’s
neighborhoods for mortgage risk• Federal government (HOLC) systematized the assessment process• Both property AND residents evaluated• Maps created from the assessor’s area descriptions
Grade A Area Description (Desirable)
Grade D Area Description (Redlined)
Racial Differences in Residential Environment:
Of the 171 largest cities in the U.S., there is not even one city where whites live in equal conditions to those of blacks
“The worst urban context in which whites reside is considerably better than the average context of black communities.”
Sampson & Wilson 1995
Dr. William J. Wilson
Dr. Robert J. Sampson
“Today’s residential segregation is not
the unintended consequence of
individual choices and of otherwise
well-meaning law or regulation but of
unhidden public policy that explicitly
segregated every metropolitan area in
the United States. The policy was so
systemic and forceful that its effects
endure to the present time.”
Segregation: Distinctive for Blacks
• Blacks are more segregated than any other group
• Segregation varies by income for Latinos & Asians, but high at
all levels of income for blacks.
• Wealthiest blacks ( > $50K) are more segregated than the
poorest Latinos & Asians ( < $15,000).
• Middle class blacks live in poorer areas than whites of similar
SES and poor whites live in better areas than poor blacks.
• Blacks show a higher preference for residing in integrated
areas than any other group.
Source: Douglas Massey 2004
Thank you
Woman-Centered Medical Home
Michael P. Marcotte, MD
Director of Quality & Safety for Women’s Services
TriHealth
Cincinnati OH
Patient-Centered Approach
Community Health
Workers
Advance Practice Nurses
RN Case Management
Centering (Group
prenatal care)
Community-based
Resources
Communication Training
Integrated Teams
Welcoming Environment
Consistent Standards
Medical Home
Proactive Screenings
50
Maternal Health Law Partnership (M-HeLP)
National Center for Medical Legal Partnershiphttp://medical-legalpartnership.org/
http://medical-legalpartnership.org/wp-content/uploads/2017/12/Health-Center-based-Medical-Legal-Partnerships.pdf
M-HeLP Key Components
• Partnership between Legal Aid and TriHealth Good Samaritan Hospital and Cincinnati Children’s Hospital Medical Center
• Nurse case managers, social workers and community health workers screen pregnant women during prenatal care for social determinants of health
• Referral to Legal Aid for women who screen positive
• Legal Aid provides advocacy for pregnant woman
• Proactive newborn handoff at Cincinnati Children’s Pediatric Primary Care Center
Data on Screening and Referral: Year 1
• 336 unique women screened – all at high risk of preterm birth
• Screening tool applied during 1400 prenatal visits
• 30% of patients screened positive for SDH
• 98% of patients agreed to referral to Legal Aid
• Legal Aid reached 98% of referred patients
• Legal Aid reduced SDH in 87% of cases
• 90% of newborn handoffs occurred within 1 week of birth
▪ Early outcomes▪ 104 M-HeLP patients delivered
▪ 85% at term
▪ 1% delivered very preterm
▪ 904 non M-HeLP patients▪ 83% at term
▪ 3% delivered very preterm (<28 weeks)
Legal Advocacy Produces Results
• Examples of reduced social determinants in M-HeLP year 1:• Prevented evictions
• Secured repairs in rental housing
• Prevented domestic violence by securing protective orders
• Established eligibility for Food Stamps and other public benefits
06/2013 - Cradle Cincinnati launch.07/2013 - StartStrong launch.03/2014 - ECS home visits; Community Conversations.
06/2014 - CHW begins; Community Feast.…
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Since 2014 -- 600 births, no extreme preterm births and no Infant Deaths!
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$1.73
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$1.27
$1.45
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$0.38
$0.58
$0.65
$4.01 million
$2.66 million
$0.0
$0.5
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$4.0
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2009-201289 births
2013-201691 births
Mill
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rsEstimated maternal and newborn hospital costs for singleton deliveries by birthweight
distribution (25-36 weeks gestational age), 2009-2012 vs 2013-2016, ZIP Code 45229
25-27 Weeks 28-31 Weeks 32-33 Weeks 34-36 WeeksSource:Birth data from Hamilton County Public HealthEstimated costs data from Gilbert WM, Nesbitt TS, Danielsen B. The cost of prematurity: quantification by gestational age and birth weight. Obstetrics and Gynecology (2003) 102(3):488-92
Reduction in extreme PTBs led to estimated $1.35 million saved, or $337k/year
Avondale Cost Savings